Is Ba3In2O6a high-Tcsuperconductor?

It has been suggested that Ba3In2O6might be a high-Tcsuperconductor. Experimental investigation of the properties of Ba3In2O6was long inhibited by its instability in air. Recently epitaxial Ba3In2O6with a protective capping layer was demonstrated, which finally allows its electronic characterization. The optical bandgap of Ba3In2O6is determined to be 2.99 eV in-the (001) plane and 2.83 eV along thec-axis direction by spectroscopic ellipsometry. First-principles calculations were carried out, yielding a result in good agreement with the experimental value. Various dopants were explored to induce (super-)conductivity in this otherwise insulating material. NeitherA- norB-site doping proved successful. The underlying reason is predominately the formation of oxygen interstitials as revealed by scanning transmission electron microscopy and first-principles calculations. Additional efforts to induce superconductivity were investigated, including surface alkali doping, optical pumping, and hydrogen reduction. To probe liquid-ion gating, Ba3In2O6was successfully grown epitaxially on an epitaxial SrRuO3bottom electrode. So far none of these efforts induced superconductivity in Ba3In2O6,leaving the answer to the initial question of whether Ba3In2O6is a high-Tcsuperconductor to be 'no' thus far.

Study of High-Transverse-Momentum Higgs Boson Production in Association with a Vector Boson in the qqbb Final State with the ATLAS Detector

This Letter presents the first study of Higgs boson production in association with a vector boson (V=W or Z) in the fully hadronic qqbb final state using data recorded by the ATLAS detector at the LHC in proton-proton collisions at sqrt[s]=13  TeV and corresponding to an integrated luminosity of 137  fb^{-1}. The vector bosons and Higgs bosons are each reconstructed as large-radius jets and tagged using jet substructure techniques. Dedicated tagging algorithms exploiting b-tagging properties are used to identify jets consistent with Higgs bosons decaying into bb[over ¯]. Dominant backgrounds from multijet production are determined directly from the data, and a likelihood fit to the jet mass distribution of Higgs boson candidates is used to extract the number of signal events. The VH production cross section is measured inclusively and differentially in several ranges of Higgs boson transverse momentum: 250-450, 450-650, and greater than 650 GeV. The inclusive signal yield relative to the standard model expectation is observed to be μ=1.4_{-0.9}^{+1.0} and the corresponding cross section is 3.1±1.3(stat)_{-1.4}^{+1.8}(syst)  pb.

Measurement of the Centrality Dependence of the Dijet Yield in p+Pb Collisions at sqrt[s_{NN}]=8.16 TeV with the ATLAS Detector

ATLAS measured the centrality dependence of the dijet yield using 165  nb^{-1} of p+Pb data collected at sqrt[s_{NN}]=8.16  TeV in 2016. The event centrality, which reflects the p+Pb impact parameter, is characterized by the total transverse energy registered in the Pb-going side of the forward calorimeter. The central-to-peripheral ratio of the scaled dijet yields, R_{CP}, is evaluated, and the results are presented as a function of variables that reflect the kinematics of the initial hard parton scattering process. The R_{CP} shows a scaling with the Bjorken x of the parton originating from the proton, x_{p}, while no such trend is observed as a function of x_{Pb}. This analysis provides unique input to understanding the role of small proton spatial configurations in p+Pb collisions by covering parton momentum fractions from the valence region down to x_{p}∼10^{-3} and x_{Pb}∼4×10^{-4}.

Search for New Phenomena in Two-Body Invariant Mass Distributions Using Unsupervised Machine Learning for Anomaly Detection at sqrt[s]=13 TeV with the ATLAS Detector

Searches for new resonances are performed using an unsupervised anomaly-detection technique. Events with at least one electron or muon are selected from 140  fb^{-1} of pp collisions at sqrt[s]=13  TeV recorded by ATLAS at the Large Hadron Collider. The approach involves training an autoencoder on data, and subsequently defining anomalous regions based on the reconstruction loss of the decoder. Studies focus on nine invariant mass spectra that contain pairs of objects consisting of one light jet or b jet and either one lepton (e,μ), photon, or second light jet or b jet in the anomalous regions. No significant deviations from the background hypotheses are observed. Limits on contributions from generic Gaussian signals with various widths of the resonance mass are obtained for nine invariant masses in the anomalous regions.

Observation of WZγ Production in pp Collisions at sqrt[s]=13 TeV with the ATLAS Detector

This Letter reports the observation of WZγ production and a measurement of its cross section using 140.1±1.2  fb^{-1} of proton-proton collision data recorded at a center-of-mass energy of 13 TeV by the ATLAS detector at the Large Hadron Collider. The WZγ production cross section, with both the W and Z bosons decaying leptonically, pp→WZγ→ℓ^{'}^{±}νℓ^{+}ℓ^{-}γ (ℓ^{(^{'})}=e, μ), is measured in a fiducial phase-space region defined such that the leptons and the photon have high transverse momentum and the photon is isolated. The cross section is found to be 2.01±0.30(stat)±0.16(syst)  fb. The corresponding standard model predicted cross section calculated at next-to-leading order in perturbative quantum chromodynamics and at leading order in the electroweak coupling constant is 1.50±0.06  fb. The observed significance of the WZγ signal is 6.3σ, compared with an expected significance of 5.0σ.

Supplement Type Impact on the Performance and Nutrient Dynamics of Nursing Does and Kids Raised in Woodlands

The influence of different supplement types on the performance and nutrient dynamics of goats stocked in woodlands is not known. The objective of this study was to evaluate the effect of supplement type on the performance and the concentration of fecal nutrients of nursing does and the performance of kids raised in woodlands. One group of goats (SG, 9 does; 18 kids) was allowed supplemental grazing in adjacent silvopasture plots for 3-4 h daily and another group (SF, 8 does; 15 kids) was supplemented with corn (0.5% of metabolic weight) and ad libitum hay. Vegetation samples were collected and analyzed for productivity and quality (crude protein, CP; acid detergent fiber, ADF; neutral detergent fiber, NDF). The quality of the hay (N, ADF, NDF) and fecal samples (N, P, Ca) was analyzed. The animals' live weight, FAMACHA score, and body condition score were collected. The browsing height for does consuming woodland vegetation was measured. Data were analyzed using the GLM procedure, Mixed procedure, and MEANS procedure in SAS 9.4. SG does showed better FAMACHA scores vs. SF does (p < 0.05). Fecal N and ADF were greater (p < 0.0001) in SG does vs. SF does. The findings showed a better performance and greater concentration of fecal nutrients in SG does vs. SF does, suggesting grazing quality pastures is a better option than using feedstuffs to supplement nursing does in woodland.

Combined Measurement of the Higgs Boson Mass from the H→γγ and H→ZZ^{*}→4ℓ Decay Channels with the ATLAS Detector Using sqrt[s]=7, 8, and 13 TeV pp Collision Data

A measurement of the mass of the Higgs boson combining the H→ZZ^{*}→4ℓ and H→γγ decay channels is presented. The result is based on 140  fb^{-1} of proton-proton collision data collected by the ATLAS detector during LHC run 2 at a center-of-mass energy of 13 TeV combined with the run 1 ATLAS mass measurement, performed at center-of-mass energies of 7 and 8 TeV, yielding a Higgs boson mass of 125.11±0.09(stat)±0.06(syst)=125.11±0.11  GeV. This corresponds to a 0.09% precision achieved on this fundamental parameter of the Standard Model of particle physics.

Search for Dark Photons in Rare Z Boson Decays with the ATLAS Detector

A search for events with a dark photon produced in association with a dark Higgs boson via rare decays of the standard model Z boson is presented, using 139  fb^{-1} of sqrt[s]=13  TeV proton-proton collision data recorded by the ATLAS detector at the Large Hadron Collider. The dark boson decays into a pair of dark photons, and at least two of the three dark photons must each decay into a pair of electrons or muons, resulting in at least two same-flavor opposite-charge lepton pairs in the final state. The data are found to be consistent with the background prediction, and upper limits are set on the dark photon's coupling to the dark Higgs boson times the kinetic mixing between the standard model photon and the dark photon, α_{D}ϵ^{2}, in the dark photon mass range of [5, 40] GeV except for the ϒ mass window [8.8, 11.1] GeV. This search explores new parameter space not previously excluded by other experiments.

In search of lost ergots: phylogenetic re-evaluation of Claviceps species in Japan and their biogeographic patterns revealed

Claviceps (Clavicipitaceae, Hypocreales) was erected in 1853, although ergotism had been well-known for a much longer time. By 2000, about 70 taxa had been described in Claviceps, of which eight species and six varieties were based on Japanese type or authentic specimens. Most of these Japanese Claviceps taxa are based on lost specimens or have invalid names, which means many species practically exist only in the scientific literature. The ambiguous identities of these species have hindered taxonomic resolution of the genus Claviceps. Consequently, we sought and collected more than 300 fresh specimens in search of the lost Japanese ergots. Multilocus phylogenetic analyses based on DNA sequences from LSU, TEF-1α, TUB2, Mcm7, and RPB2 revealed the phylogenetic relationships between the Japanese specimens and known Claviceps spp., as well as the presence of biogeographic patterns. Based on the phylogenetic analysis, host range and morphology, we re-evaluated Japanese Claviceps and recognised at least 21 species in Japan. Here we characterised 14 previously described taxa and designated neo-, lecto- and epi-types for C. bothriochloae, C. imperatae, C. litoralis, C. microspora, C. panicoidearum and C. yanagawaensis. Two varieties were elevated to species rank with designated neotypes, i.e. C. agropyri and C. kawatanii. Six new species, C. miscanthicola, C. oplismeni, C. palustris, C. phragmitis, C. sasae and C. tandae were proposed and described. Taxonomic novelties: New species: Claviceps miscanthicola E. Tanaka, Claviceps oplismeni E. Tanaka, Claviceps palustris E. Tanaka, Claviceps phragmitis E. Tanaka, Claviceps sasae E. Tanaka, Claviceps tandae E. Tanaka; New status and combination: Claviceps agropyri (Tanda) E. Tanaka, Claviceps kawatanii (Tanda) E. Tanaka; Typifications (basionyms): Lecto- and epitypification: Claviceps yanagawaensis Togashi; Neotypifications: Claviceps purpurea var. agropyri Tanda, Claviceps bothriochloae Tanda & Y. Muray, Claviceps imperatae Tanda & Kawat., Claviceps microspora var. kawatanii Tanda, Claviceps litoralis Kawat., Claviceps microspora Tanda, Claviceps panicoidearum Tanda & Y. Harada; Resurrection: Claviceps queenslandica Langdon. Citation: Tanaka E, Tanada K, Hosoe T, Shrestha B, Kolařík M, Liu M (2023). In search of lost ergots: phylogenetic re-evaluation of Claviceps species in Japan and their biogeographic patterns revealed. Studies in Mycology 106: 1-39. doi: 10.3114/sim.2022.106.01.

Alarm Fatigue among Nurses Working in Critical Care Setting in a Tertiary Hospital, Nepal

Background Alarm fatigue is a well-recognized patient safety concern in critical care settings. It occurs when nurses become overwhelmed by the total number of alarm signals which can result in alarm desensitization and eventually contributes to missing of serious and important changes in a patient's condition, thus failing to respond properly. Objective To find out alarm fatigue and its associated factors among nurses working in critical care setting. Method A cross-sectional study design with convenient sampling technique was used to select 56 nurses working at different critical care settings in Dhulikhel Hospital. A selfconstructed semi structured questionnaire and nurses alarm fatigue questionnaire was used for the survey. Frequency, percentage, mean and standard deviation were used for descriptive statistics whereas Independent t-test and One-way ANOVA were used for inferential statistics. Result The result shows that more than half of the nurses were less than 25 years, single and more than two-third of the participants worked in Adult Intensive Care Unit. Out of total obtainable score 44, the overall mean score of the Alarm Fatigue was 28.03±12.813. The result showed that there was no significant difference between alarm fatigue and selected socio-demographic and work related characteristics. Conclusion The alarm fatigue among nurses working in critical care settings was found to be higher in this study. Since alarm fatigue is directly related to patients' safety, the effective management of medical device alarms can reduce alarm fatigue and prevent potentially dangerous outcomes.

Phenotypic and functional characterisation of synovial fluid-derived neutrophils in knee osteoarthritis and knee infection

OBJECTIVE

An increase in the number of neutrophils (NEUs) has long been associated with infections in the knee joints; however, their impact on knee osteoarthritis (KOA) pathophysiology remains largely unexplored.

DESIGN

This study compared the phenotypic and functional characteristics of synovial fluid (SF)-derived NEUs in KOA and knee infection (INF).

RESULTS

KOA NEUs were characterised by a lower expression of CD11b, CD54, and CD64 and higher expression of CD62L, TLR2, and TLR4 compared with INF NEUs. Except for CCL2, lower levels of inflammatory mediators and proteases were detected in KOA SF than in INF SF. Functionally, KOA NEUs displayed increased reactive oxygen species production and phagocytic activity compared with INF NEUs. Moreover, KOA and INF NEUs differed in cell sizes, histological characteristics of the surrounding synovial tissues, and their effects on the endothelial cells assessed by human umbilical vein endothelial cells. When KOA patients were subdivided based on the SF NEU abundance, patients with high NEUs (10%-60%) were characterised by i) elevated SF protein levels of TNF-α, IL-1RA, MMP-9, sTREM-1, VILIP-1 and ii) lower CD54, CD64, TLR2 and TLR4 expression compared to patients with low NEUs (<10%). Analysis of paired SF samples suggests that low or high NEU percentages, respectively, persist throughout the course of disease.

CONCLUSIONS

Our findings suggest that NEU may play a significant role in KOA pathophysiology. Further studies should explore the mechanisms that contribute to the increased number of NEUs in SF and the clinical consequences of neutrophilic phenotype in KOA.

Clinical Characteristics of Cataract Patients and Outcome of Cataract Surgery in Tertiary Care Hospital in Central Nepal

Background Cataract remains the leading cause of avoidable blindness in low-income countries such as Nepal. Despite the availability of surgical interventions for cataract in leading institutions, still a large number of patients from remote areas delay or have difficulty in getting treatment, present late or with complications. Objective To determine the clinical characteristics and visual outcome of patients undergoing cataract surgery in Tertiary Care Hospital in Central Nepal. Method We retrospectively reviewed the medical records of 138 patients who underwent cataract surgery at a tertiary care hospital from January 2018 to September 2022. R version 4.0.3 was used for the data analysis. Categorical variables are presented as frequency (percentages) and the numerical ones are presented as mean (standard deviation). Result During follow-up visits between one to three weeks, 91.9% out of 135 patients had normal/near normal presenting visual acuity and with best correction it was 96.9% out of 131 patients. About 1.6% out of 124 operated eyes still had moderate visual impairment after best correction when they visited for follow-up at 12 weeks. Conclusion The study findings underline the ongoing gap in increasing access to cataract treatment, given the large proportion of individuals who still presented extremely late.

PSIII-13 Performance and Resiliency of Lactating Does and Their Kids in Woodlands with Supplemental Feedstuffs or Grazing

Previous woodland-grazing studies reported poor performance of young, growing goats and recommended for supplemental feed. However, not much is known about strategies to supplement lactating animals stocked in woodlands. The objective of this study was to evaluate the performance and resiliency against gastrointestinal (GI) parasites of lactating does and their kids stocked in woodlands with supplemental grazing or feedstuffs. The study was conducted in six woodland plots and adjacent silvopasture plots were used for supplemental grazing. Seventeen lactating Kiko does with their kids (33) were divided into two groups. Each group was assigned to separate sets of woodland plots and rotated among those plots throughout the study period. One group (Group 1) was allowed to supplemental grazing in adjacent silvopasture plots for 3-4 hours daily and another group (Group 2) was supplemented with ad libitum hay and corn (0.5% of metabolic weight). Animal performance data (live weight, FAMACHA score, and body condition score (BCS)) were collected at the beginning after a 5-day-adjustment period, fortnightly during the study, and at the end. Vegetation samples from woodland and silvopasture plots were collected and analyzed for biomass and quality (CP, ADF, NDF, TDN). Fecal samples were collected and analyzed for GI parasites from animals having FAMACHA score 3 and higher. Animal performance and forage quality data were analyzed using GLM procedure, forage biomass data using Mixed model, and fecal egg-count data using the non-parametric (NPAR1WAY) procedure in SAS 9.4. Silvopasture produced greater biomass (60%) with higher quality (p&lt; 0.0001) vs. woodland. Group-1 does showed better FAMACHA score and less prevalence of GI-parasite infestation vs. Group-2 does (p&lt; 0.05). Group-1 kids had lower coccidia count vs. Group-2 kids (p&lt; 0.05). In conclusion, supplemental grazing was better for resiliency against GI parasites in lactating does and young kids than supplemental feeding.

176 Costs for Supplementing Small Ruminants Under the Various Grazing-Based Production Systems

The supplementary feeding costs of small ruminants can be substantial when there is not much vegetation available for grazing or browsing. However, such costs have not been reported well and the strategies to minimize them not discussed enough. The objective of this study was to quantify the feeding costs involved in supplementing small ruminants under grazing-based production systems. Grazing studies were conducted from July to October in 2021 (88 d) in woodlands with lactating Kiko does (17) along with their young kids (33). Animals were divided into two groups (1 & 2) and randomly allocated to three woodland plots each for rotational stocking. Group 1 was allowed to rotationally graze in nearby silvopasture plots for 3-4 hours daily and Group 2 was supplemented with ad lib. hay and corn (0.5% metabolic wt.). Another study was conducted from October to December 2021 (70 d) involving 56 Kiko goats and 18 Katahdin-St. Croix ewes. During this study, there was not much foliage available, and animals were supplemented with hay (ad lib.) and corn (0.5% live wt.). Cost and amount of hay and corn used for supplementation were recorded. Data were analyzed in Excel for descriptive statistics. In the woodland study, cost for supplementing animals was $0.13 per animal per day, with 86% of the cost accounted for hay and 14% for corn. In the second study, when not much vegetation was available for grazing, cost for supplementing animals was $0.43 per animal per day, with hay cost accounting for 77% and remaining for corn. Findings of this study suggest that planted forages can be used to replace the need for purchased feed during the forage-growing period. The costs of supplementation can be significantly high during the lean period of forage production.

Morphometric Analysis of Posterior Fossa and Foramen Magnum among Pediatric Age Group 6 to 16 Years

Background Configuration and size of the foramen magnum and posterior cranial fossa plays an important role in the pathophysiology of various disorders like Chiari malformations, basilar invagination etc. Thus, a fundamental knowledge of normal anatomy of this region is important to the clinician for diagnosis and treatment. However, we couldn't find any anatomical study related to the concerned topic among the pediatric population aged 6 to 16 years in Nepal to the best of our knowledge. Objective To attain the baseline results (volume of bony part of posterior cranial fossa and the surface area of foramen magnum) that will help in the better diagnosis, classification, and treatment of diseases related to posterior fossa and craniovertebral junction and serve as a future reference defining an anatomic range in our region. Method This is a retrospective prospective observational study conducted from 1st February 2021 to 31st January 2022 at Dhulikhel Hospital, Kathmandu University Hospital, Kavrepalanchowk, Nepal. We used convenient sampling technique to fulfil our sample size. We considered 68 patients, who got recruited either from our emergency and OPD departments and were fulfilling our criteria of inclusion. Upon the recruitment, 68 consecutive head CT scan of pediatric patients with normal reports (without any bony or soft-tissue abnormality) were studied. Volume of the posterior fossa was calculated with the help of inbuilt "advanced work station - 3D volume calculator" program in 128 slices - SOMATOM PERSPECTIVE CT Scanner from Siemens, Germany. The area of the foramen magnum was calculated using formula πr2 , where r is average radius calculated from obtained antero-posterior and transverse diameter. Result The age of the patients ranged between 6 and 16 years with the mean age of 10.56 ± 3.38 years with male to female distribution of 1: 1.125. The mean volume of the posterior fossa was 165.61 ± 8.52 mm3 . The mean AP diameter, transverse diameter, and the surface area of foramen magnum were 3.31 ± 0.12 mm, 2.72 ± 0.12 mm, and 28.60 ± 0.09 mm2 respectively. Conclusion Normal ranges of volume of posterior cranial fossa and various dimensions and surface area of foramen magnum of pediatric population were determined using CT scans, which could serve as future reference in Nepal.

Prevalence and Factors Associated with Postpartum Depression among Mothers Visiting Immunization Clinic at Birendranagar Municipality, Surkhet, Nepal

Background Postpartum depression (PPD) is a disabling but treatable mental disorder that represents one of the most common complications of childbearing which can exert a wide range of effect on social, physical and mental health conditions of the mother and baby. Objective To identify the prevalence and factors associated with postpartum depression among mothers visiting immunization clinic at Birendranagar Municipality, Surkhet in year 2020. Method This study was a cross-sectional study. A total of 347 postpartum mothers were interviewed for data collection. Validated Nepali version of Edinburg Postnatal Depression Scale (EPDS) was used to identify postpartum depression. These mothers were permanent resident of Birendranagar who had delivered their babies in municipal hospital. Analysis was done using SPSS version 21.0. Chi square test was applied to identify association of postpartum depression with major interest of variables namely parity of mother, sex of a baby and recent planned or unplanned pregnancy. Odds ratio (OR) was calculated with 95% Confidence Interval (CI). Result The prevalence of postpartum depression was found to be 32.9% (27.9%, 37.8%). Several factors which were significantly associated with postpartum depression were; sex of the baby, history of abortion and recent pregnancy planned or unplanned. Conclusion Nearly one-third of postpartum mothers had depression. Hence screening of mothers for depression is of prime importance throughout the continuum of care. Likewise, the factors identified for postpartum depression needs to be taken care of well in advance for healthy mother and a baby.

Ultrasonographic Evaluation of Inferior Vena Cava: Aorta Index with a Cut-off Value of 1.0 as a Predictor for Hypotension after Induction of General Anesthesia; An observational study

Background Hypotension after induction of general anesthesia (GA) is common due to pre-existing hypovolemia and has adverse effects on organ function. Out of several methods to predict post-induction hypotension, nowadays Inferior Vena Cava: Aorta (IVC: Ao) index has been studied with different cut-off values. However, limited studies have been performed in our part of the world. Objective To evaluate the efficacy of pre-induction Inferior Vena Cava: Aorta index with a cutoff value of 1.0 for predicting the occurrence of post-induction hypotension after general anesthesia in the Nepalese population. Method A total of 100 patients of ASA I and II, aged more than 18 years posted for elective surgeries under general anesthesia were enrolled in this cross-sectional, observational study. Ultrasonographic guided Inferior Vena Cava: Aorta index was calculated and based on a cut-off value of 1.0, two groups were formed. Seventy patients in group A with Inferior Vena Cava: Aorta index less than 1.0 and 30 patients in group B with Inferior Vena Cava: Aorta index more than 1.0 were enrolled. Vitals parameters were recorded every minute for five minutes after induction of general anesthesia. Incidence of hypotension was the primary outcome. Statistical analysis was done using student t-test, ANOVA test and Chi-square test. Result Inferior Vena Cava: Aorta index with cut-off value of 1.0 predicted post-induction hypotension with excellent efficacy. Total 65 patients developed post-induction hypotension, out of which 63 patients had Inferior Vena Cava: Aorta index less than 1.0. Conclusion We concluded that pre-induction Inferior Vena Cava: Aorta index with cut-off value of 1.0 have high diagnostic accuracy with high degree of sensitivity and specificity to predict hypotension after induction of general anesthesia.

Isolation and Intensive Care (ICU) Service, Surge Capacity and Pandemic Training in Government Designated COVID-19 Clinics and Hospitals of Nepal

Background The coronavirus pandemic preparedness and response activities began in Nepal after the detection of the first case on 24 January 2020. Highest daily case record in June 2020 was 671, but it reached above 5,000 in October 2020. Objective This study assessed preparedness and response status of government designated COVID-19 clinics and various level hospitals. Method A web-based survey was conducted among government designated COVID-19 clinics and Level hospitals in June 2020. The Medical Operations Division of the COVID-19 Crisis Management Center (CCMC) retained contact list of focal person in each facility for regular updates. Forty-nine out of 125 clinics and all level hospitals (five Level-1, 12 Level-2, three Level-3) provided responses. Result There were 25 or less isolation beds in the majority of COVID-19 clinics (83.7%) and Level-1 hospitals (60%), whereas the majority of Level-2 (92%) and Level-3 hospitals (67%) had arranged >25 beds. Only five clinics, one Level-1 hospital, six Level-2 and two Level-3 hospitals had a surge capacity of additional 20 or more isolation beds. Only one-fourth of the designated health facilities had arranged separate isolation facility for vulnerable population. Majority of the designated clinics and Level-1 hospitals had five or less functional ICU beds and functional ventilators. Very few Level-2 hospitals had > 10 ICU beds and > 10 ventilators. Healthcare workers in the majority of facilities were trained on donning/doffing, hand washing, swab collection, and healthcare waste management, but, a very few received formal training on patient transport, dead body management, epidemic drill, and critical care. Conclusion This study revealed insufficient preparation in COVID-19 facilities during the initial phase of pandemic. The findings were utilized by the government stakeholders at central, provincial and local levels for scaling up surge capacity and improving health services at the time of case surge. As the pandemic itself is a dynamic process, periodic assessments are needed to gauze preparedness and response during different phases of disease outbreak.

Oral Solid Dosage form Modification in Community Pharmacies of Kavrepalanchok and Bhaktapur Districts of Nepal

Background People may modify their oral solid dosage form of medicine to deal with problem faced during medicine administration. The modification of dosage form may adversely affect the quality, safety and efficacy of the medicine. Objective To investigate the causes and practices of oral solid dosage form modification among the consumers going to community pharmacies. Method A descriptive, cross-sectional study was conducted in five community pharmacies of Kavrepalanchok and Bhaktapur districts of Nepal. The consumers visiting these pharmacies for their oral solid dosage form of medicine were invited to participate in interview using structured questionnaire. Result Among 419 participants,13.6% of participants reported having problem of taking intact medicine. Most of them (12.4% of total participants) experienced difficulty swallowing the medicine. The swallowing difficulty is significantly associated with age and sex (p < 0.05). Around one third (36.8%) of participant with medicine administration problem modified the dosage form of medicines. One quarter of medicine dosage form modifications (25.0%) were inappropriate. Medicine dosage form modification is associated with age and number of daily medicine intake (p < 0.05). Among participants modifying dosage form of medicines, 66.7% were advised to do so mainly by family and friends; 33.3% were modifying on their own and 76.2% were unaware of possible effects of medicine dosage form modification. About 62.3% of total participants were never asked about any problems on taking medicines by doctor/pharmacists. Conclusion Difficulty swallowing medicines and medicine dosage form modification were prevalent in the Nepalese population. Medicine dosage form modifications also involved inappropriate modifications due to specialized design of such dosage forms. So, it seems important to provide proper counseling while dispensing such dosage forms.

Comparative Study between the Use of Pigtail Catheters and Traditional Chest Tube Drain in Cases with Pneumothorax

Background Pneumothorax is a condition in which air or other gas is present in the pleural cavity. Mainstay of management of pneumothorax is to remove the air from the pleural space usually done by chest tube insertion. There is still uncertainty whether minimal invasive management with pigtail catheter is sufficient for the management of pneumothorax. Objective To find the effectiveness, safety, tolerability, efficacy of pigtail catheters and large bore chest tubes. Method Prospective comparative study was done in Dhulikhel Hospital between August 2019 till August 2021. Chest tube insertion used to be the only available treatment modality till December 2020 (15 months). Following January 2021 after obtaining ethical clearance for use of pigtail insertion for pneumothorax, this treatment modality was done (8 months). Result Among 76 patients, 52(68.4%) underwent a large bore chest tube and 24 (34.6%) pigtail catheter patients. Mean age of the patients was 48 years (SD 18.01). Duration of hospital stay and length of hospital stay was more in large bore catheters and less in pigtail catheters. Eight hours post tube placement of the expansion of the lungs was present in pigtail and was statistically significant. Pain killer used in pigtail catheters was limited to Non-steroidal anti-inflammatory drugs, for large bore catheter opioids were added and were statistically significant. Conclusion Pigtail catheter is nearly effective as compared to traditional wide bore catheters.

High success and low recurrence with shorter treatment regimen for multidrug-resistant TB in Nepal

SETTING:

Nine drug-resistant TB centres, some of them supported by Damien Foundation in Nepal where >80% of multidrug-resistant/rifampicin-resistant TB (MDR/RR-TB) patients are treated.

OBJECTIVE:

To assess the uptake, effectiveness and safety of the 9–12-month shorter treatment regimen (STR) in MDR/RR-TB patients registered from January 2018 to December 2019.

DESIGN:

This was a cohort study involving secondary programme data.

RESULTS:

Of 631 patients, 301 (48.0%) started and continued STR. Key reasons for ineligibility to start/continue STR were baseline resistance or exposure to second-line drugs (62.0%), contact with extensively drug-resistant TB (XDR-TB) or pre-XDR-TB (7.0%) patients and unavailability of STR drugs (6.0%). Treatment success was 79.6%; unsuccessful outcomes were death (12.0%), lost to follow-up (5.3%), failure (2.7%) and not evaluated (0.7%). Unsuccessful outcomes were significantly associated with HIV positivity and patient age ⩾55 years, with adjusted relative risk of respectively 2.39 (95% CI 1.52–3.77) and 3.86 (95% CI 2.30–6.46). Post-treatment recurrence at 6 and 12 months was respectively 0.5% and 2.4%. Serious adverse events (SAEs) were seen in 15.3% patients — hepatotoxicity and ototoxicity were most common.

CONCLUSION:

STR had a modest uptake, high treatment success and low post-treatment recurrence. For proper detection and management of SAEs, improving pharmacovigilance might be considered. Availability of rapid diagnostic test for second-line drugs is crucial for correct patient management.

Peak Systolic Velocity in Middle Cerebral Artery in Patients with Severe Traumatic Brain Injury as an Indicator of Detrimental Rise in Intracranial Pressure

Background Intracranial pressure (ICP) is the major concern for neurosurgeons while treating patients with severe traumatic brain injury, as any troublesome escalation in intracranial pressure heralds feared complications leading to definite morbidity or even mortality. Objective This study focuses on analyzing the correlation between peak systolic velocity in middle cerebral artery derived from transcranial doppler ultrasonographic spectral analysis and intracranial pressure values derived from invasive intracranial pressure monitoring system in a patient with severe traumatic brain injury. Method A prospective observational study was performed using a convenience sample technique including all adult patients with severe traumatic brain injury who had invasive intracranial monitors placed as part of their clinical care. Transcranial doppler ultrasonography was performed with a 2 MHz linear probe of ACUSON X300 ultrasound system while simultaneous intracranial pressure readings were obtained directly from invasive intracranial pressure monitoring. The association between peak systolic velocity in the middle cerebral artery and invasive intracranial pressure was assessed with Pearson's correlation coefficient. Result One hundred one transcranial doppler ultrasound spectral analysis was performed on 26 individual patients. The mean age of the population involved in this study is 43.57 years ± S.D. 19.95 (range 18-78 years), with male preponderance in a ratio of 5.5:1. Pearson's correlation coefficient of peak systolic velocity in middle cerebral artery and intracranial pressure was 0.715 (p < 0.000) demonstrating a significant positive correlation. With further evaluation of area under curve characteristics, peak systolic velocity in middle cerebral artery of 39.6 cm/s yielded the most favorable balance of test characteristics to diagnose elevation of intracranial pressure, with a resulting sensitivity of 82.1% and specificity of 84.4%. Conclusion Peak systolic velocity in middle cerebral artery can be explored further as a dependable screening tool to evaluate intracranial pressure among patients with severe traumatic brain injury in settings with unavailability of invasive intracranial pressure monitoring facilities.

Supraclavicular Brachial Plexus Block: Comparison of Varying Doses of Dexmedetomidine with Ropivacaine

Background Alpha-2 adrenergic receptor agonists have been the focus of interest nowadays as an adjuvant to local anesthesia due to its excellent sedative, analgesic, antihypertensive, anesthetic sparing and hemodynamic stabilizing properties. The ideal dose of dexmedetomidine for brachial plexus block is matter of debate. Objective To find the appropriate minimal dose of dexmedetomidine with desired clinical effects and minimal side-effects, we compared different doses (25 mcg, 50 mcg, 75 mcg and 100 mcg) of dexmedetomidine as an adjuvant to ropivacaine. Method One hundred fifty patients of ASA I and II, aged (18-60) years, weighing (50-60) kilograms undergoing upper limb surgeries under brachial plexus block were enrolled in this prospective, double blind, randomized control study. Patients in all group received 19 ml of 0.5% ropivacaine in common. In addition; group RD25, RD50, RD75 and RD100 received 25 mcg, 50 mcg, 75 mcg and 100 mcg of dexmedetomidine diluted in 1 ml of normal saline (NS) respectively whereas group RD00 received only 1 ml of NS. The duration of analgesia was the primary outcome whereas block characteristics, hemodynamic parameters, oxygen saturation, sedation score and adverse effects were taken as secondary outcome. Statistical analysis was done using ANOVA test, Chi-square test and Scheffe's multiple comparison tests. Result The demographic profile and baseline hemodynamic variables were comparable in all five groups. Increasing dose of dexmedetomidine showed significant improvement in block characteristics but associated with increase in sedation and incidence of bradycardia. Conclusion We conclude that dexmedetomidine 50 mcg would be an appropriate dose as adjuvant to local anesthesia in brachial plexus block.

Psychosocial Problems among the Adolescent School Students of Dhulikhel Municipality

Background Adolescence is a period when an individual experiences a variety of biological, psychological and social changes. These multiple changes during the developmental period can make the adolescents vulnerable to mental health problems. Therefore early detection of psychosocial problems and addressing the need of the adolescents are crucial for promoting their mental health. Objective To assess psychosocial problems and its associated factors among school going adolescents of Dhulikhel, Nepal. Method A descriptive cross sectional study was conducted among 513 adolescents studying in grade 8 to 12 of randomly selected schools of Dhulikhel Municipality. Data were collected by using structured questionnaire and Pediatric Symptom Checklist-Youth Report (Y-PSC). Descriptive and inferential analysis was done using Statistical Package for Social Sciences version 20. Result Out of 513 adolescent students, a total of 133(25.9%) of the adolescents were found to have psychosocial problems. There was significant association between psychosocial problems and respondents' variables like age, grade, parental education status, respondents' living status, perceived family disputes, perceived marital problems of parents, relationship problem with family, stress of failure in study, punishment faced in home and school, experienced sexual harassment and death of loved ones. Conclusion Various family related factors and stressful life events of adolescents are associated with the psychosocial problems. Hence early intervention focusing on awareness and modification of stressful life events is required.

Burden of arrhythmia in hospitalized patients with cannabis use related disorders: analysis of 2016-2018 national inpatient sample

Funding Acknowledgements

Type of funding sources: None.

Introduction

Cannabis is being more widely use as a recreational substance worldwide. There have been case reports and systematic review describing the association of cannabis use and cardiac arrhythmia (1).

Purpose

We sought out to measure the prevalence of different types of cardiac arrhythmia in hospitalizations associated with cannabis use disorder.

Methods

We queried January 2016 to December 2018 National Inpatient Sample (NIS) databases to identify adult (≥18 yrs) hospitalizations in the US with a diagnosis of cannabis use related disorders. Patients with an associated diagnosis of arrhythmias were also identified based on appropriate ICD-10 CM codes. We used the Chi-square test to evaluate the differences between binary or categorical variables, and Student’s t-test for continuous variables. Multivariate logistic regression was used in outcomes analysis to adjust for potential hospital and patient-level confounders (age, sex, race, diabetes, heart failure, chronic kidney disease, anemia, obesity, elixhauser co-morbidity index, hospital location, teaching status, bed size, income status and others). The discharge weights provided in the databases were used to calculate the national estimates. STATA 16.1 software was used to perform all statistical analysis.

Results

We identified 2,457,544 hospitalizations associated with cannabis use related disorders across three years. Of which, 187,825 (7.6%) were associated with any arrhythmia. We found that atrial fibrillation was the most associated arrhythmia. The complete list of types of arrhythmia and their prevalence are described in Figure-1. Patients with arrhythmia group were older (mean age 50.5 vs 38.3 yrs; P &lt; 0.01) and had higher co-morbidity (% of &gt;3 Elixhauser comorbidity score 94.1% vs 60.6%; P &lt; 0.01). After adjusting for patient and hospital-level confounders, we observed arrhythmia group was associated with higher odds of in-hospital mortality compared to the group without arrhythmia [Odds Ratio (OR): 4.5 (4.09 – 5.00); P &lt; 0.01]. We also observed statistically significant increase in hospitalization length of stay due to the status of any arrhythmia [5.7 vs 5.1 days; P &lt; 0.01].

Conclusion

The prevalence of Afib is high in hospitalizations associated with cannabis use. Hospitalizations associated with cannabis use disorder and any arrhythmia are associated with higher in-hospital mortality and LOS. Therefore, all electrocardiograms should be scrutinized in hospitalized cannabis users. However, further prospective studies are necessary to endorse our study results. Abstract Figure.

Burden of dementia in atrial fibrillation hospitalizations- analysis of national inpatient sample 2016-2018

Funding Acknowledgements

Type of funding sources: None.

Introduction

Atrial fibrillation is a common disorder in the elderly population and a known risk factor for stroke and dementia.

Purpose

 To study the burden of dementia in Afib hospitalizations and identify the predictors of in-hospital mortality in Afib with dementia hospitalizations.

Methods

We queried January 2016 to December 2018 National Inpatient Sample (NIS) to identify adult (≥18 yrs) hospitalizations with a primary diagnosis of Afib. Hospitalizations of Afib with dementia was compared with Afib without dementia. We used the Chi-square test for differences between categorical variables, and Student’s t-test for continuous variables. Multivariate logistic regression was used in outcomes analysis to adjust for potential hospital and patient-level confounders.

Results

 We identified 1,236,540 weighted Afib hospitalizations across three years. Of which, 79,405 (6.4%) of them were associated with dementia. Afib with dementia hospitalizations were associated with older age (mean age 83.2 vs 70.0 yrs; P &lt; 0.01), higher rate of chronic Afib (15.3% vs 7.5%; P &lt; 0.01), higher rate of comorbidity (% of &gt;3 Elixhauser comorbidity score 91.8% vs 83.6%; P &lt; 0.01). After adjusting for patient and hospital-level characteristics, we observed that Afib with dementia hospitalizations was associated with higher odds of in-hospital mortality compared to Afib without dementia [Odds Ratio (OR): 1.6 (1.4 – 1.9); P &lt; 0.01]. We also observed statistically significant association with increased LOS [4.7 vs 3.2 days; P &lt; 0.01], repeated falls [OR: 2.8 (2.5 – 3.1); P &lt; 0.01] and protein calorie malnutrition [OR: 1.9 (1.7 – 2.0); P &lt; 0.01] in Afib with dementia group.

Conclusion

Afib with dementia hospitalizations are not only associated with higher mortality, but they are also associated with higher repeated fall rates, and skilled nursing facility discharge dispositions. Co-morbidities like hypertension, CKD, obesity, HFrEF, HFpEF, OSA are associated with higher in-hospital mortality. Our study findings emphasize the burden of dementia in Afib hospitalizations and the need for prevention of poor outcomes in this population.

Obesity paradox in HFrEF hospitalizations: analysis of national inpatient sample 2016-2018

Funding Acknowledgements

Type of funding sources: None.

Introduction

Obesity is a common and known risk factor for many cardiovascular diseases. Prior studies on chronic systolic heart failure have demonstrated that obesity is inversely associated with mortality, the so-called obesity paradox.

Purpose

 To study the phenomenon of obesity paradox in HFrEF hospitalizations

Methods

We queried January 2016 to December 2018 National Inpatient Sample (NIS) to identify adult (≥18 yrs) hospitalizations with a primary diagnosis of HFrEF. Patients with an associated diagnosis of obesity and higher BMI were also identified based on appropriate ICD-10 CM codes. We used the Chi-square test to evaluate the differences between binary or categorical variables, and Student’s t-test for continuous variables. Multivariate logistic regression was used in outcomes analysis to adjust for potential hospital and patient-level confounders.

Results

 We identified 639,944 weighted HFrEF hospitalizations across three years. Of which, 130,949 (20.4%) of them were associated with obesity. HFrEF with obesity hospitalizations were associated with younger age (mean age 62.0 vs 70.7 yrs; P &lt; 0.01), lesser CAD (55% vs 61%; P &lt; 0.01), higher rate of comorbidity (% of &gt;3 Elixhauser comorbidity score 99.2% vs 94.1%; P &lt; 0.01) and higher Medicaid primary payer (18.2% vs 12.7%, P &lt; 0.01). After adjusting for patient and hospital-level characteristics, we observe statistically significant difference in odds of in-hospital mortality when HFrEF with obesity hospitalizations was compared to HFrEF without obesity [Odds Ratio (OR): 1.1 (0.8 – 1.5); P = 0.52]. We observed statistically significant association with increased LOS [6.0 vs 5.3 days; P &lt; 0.01], increased total hospitalization charges [US$ 61524 vs 55677; P &lt; 0.01] and decreased coronary catheterizations [OR: 0.7 (0.5 – 0.9); P = 0.01] in HFrEF with obesity group compared to HFrEF without obesity.

Conclusion

In this retrospective cohort of hospitalized patients with HFrEF, higher BMI and obesity was not associated with in-hospital mortality. However, it was associated with longer LOS and higher total hospitalization charges. HFrEF with obesity hospitalizations are associated with lesser left coronary catheterizations. This may be explained by lesser burden of CAD in this patient population.

Correlation between Invasive Intracranial Pressure Monitoring and Optic Nerve Sheath Diameter in Patients with Traumatic Brain Injury

Background In management of patients with traumatic brain injury, intracranial pressure holds an important place. Any untoward rise in intracranial pressure portends dreaded complications. Hence, any delay in detecting the issue is considered unacceptable. Objective This study focuses on analyzing the correlation between ultrasound derived optic nerve sheath diameter and intracranial pressure values derived from invasive intracranial pressure monitoring system in a neurosurgical patient with severe traumatic brain injury. Method A prospective observational study was performed using a convenience sample technique including all adult patients with traumatic brain injury who had invasive intracranial monitors placed as part of their clinical care. Ocular ultrasound was performed with 5 - 7.5 MHz linear probe of ACUSON X300 ultrasound system while simultaneous intracranial pressure readings were obtained directly from an invasive intracranial pressure monitoring system. The association between optic nerve sheath diameter and invasive intracranial pressure reading was assessed with the Pearson's correlation coefficient and a receiver operator characteristic curve was created to determine the optimal optic nerve sheath diameter cutoff to detect intracranial pressure > 15 cm H2O. Result One hundred and fifteen ocular ultrasounds were performed on 30 individual patients. The mean age of the population involved in this study is 42.13 years ± 1.89 with male preponderance in the ratio of 6:1. Pearson's correlation coefficient of optic nerve sheath diameter and intracranial pressure was found to be 0.844 (p < 0.000) demonstrating a significant positive correlation. The area under the receiver operating characteristic curve was found to be 0.961 (95% confidence interval = 0.93 to 0.99). Based on analysis of the receiver operating characteristic curve, optic nerve sheath diameter > 4.85 mm performed best to detect intracranial pressure > 15 cm H2 O with a sensitivity of 93.5% and specificity of 83%. Conclusion Optic nerve sheath diameter is a dependable screening tool to evaluate for elevated intracranial pressure among patients with traumatic nerve injury.

Outcome of treatment of MDR-TB or drug-resistant patients treated with bedaquiline and delamanid: Results from a large global cohort

The World Health Organization (WHO) recommends countries introduce new anti-TB drugs in the treatment of multidrug-resistant tuberculosis. The aim of the study is to prospectively evaluate the effectiveness of bedaquiline (and/or delamanid)- containing regimens in a large cohort of consecutive TB patients treated globally. This observational, prospective study is based on data collected and provided by Global Tuberculosis Network (GTN) centres and analysed twice a year. All consecutive patients (including children/adolescents) treated with bedaquiline and/or delamanid were enrolled, and managed according to WHO and national guidelines. Overall, 52 centres from 29 countries/regions in all continents reported 883 patients as of January 31st 2021, 24/29 countries/regions providing data on 100% of their consecutive patients (10-80% in the remaining 5 countries). The drug-resistance pattern of the patients was severe (>30% with extensively drug-resistant -TB; median number of resistant drugs 5 (3-7) in the overall cohort and 6 (4-8) among patients with a final outcome). For the patients with a final outcome (477/883, 54.0%) the median (IQR) number of months of anti-TB treatment was 18 (13-23) (in days 553 (385-678)). The proportion of patients achieving sputum smear and culture conversion ranged from 93.4% and 92.8% respectively (whole cohort) to 89.3% and 88.8% respectively (patients with a final outcome), a median (IQR) time to sputum smear and culture conversion of 58 (30-90) days for the whole cohort and 60 (30-100) for patients with a final outcome and, respectively, of 55 (30-90) and 60 (30-90) days for culture conversion. Of 383 patients treated with bedaquiline but not delamanid, 284 (74.2%) achieved treatment success, while 25 (6.5%) died, 11 (2.9%) failed and 63 (16.5%) were lost to follow-up.

Sensitivity and Specificity of Lateral Flow Antigen Test Kits for COVID-19 in Asymptomatic Population of Quarantine Centre of Province 3

Background Nearly after 6 months of the spread of Corona Virus Disease 19, along with the world Nepal is still trying to control the spread and prevent general population from acquiring it. With limited resources in manpower, technology and evidence it has been a difficult battle. But with time and more understanding of the virus new technology to detect the virus are coming up. It is a major breakthrough in the diagnostic field as this helps us in not only detecting the virus but also helps us to mobilize our human resources. This comes in a time where the cases are increasing at an alarming rate. Although numbers of Polymerase Chain Reaction testing have increased but due to the time consuming and the cost wise, we need a faster and equally reliable alternative. Antigen test approved by different countries can be used for point of care, screening and surveillance depending upon the requirements after calculating its sensitivity, specificity and accuracy. Objective To find out sensitivity and specificity of the Antigen test kit for COVID-19. Method Antigen tests were compared with Reverse Transcription Polymerase Chain Reaction as a reference standard in calculated sample size of 113 subjects in a high risk population. Both Reverse Transcription Polymerase Chain Reaction and antigen test were performed in a same subject with in maximum of 2 days' interval. Convenience sampling technique was used to select the subjects. Ethical approval was taken from Nepal Health Research Council before data collection. Study was done from August to September 2020 from Quarantine center of Province 3. Result There were total of 113 test carried out, among those 47 were positive and 66 were negative in Reverse Transcription Polymerase Chain Reaction. After preparing two by two table, Sensitivity and specificity of the tested was calculated which came out to be 85% and 100% respectively, with accuracy of 93.80%. Conclusion Even though the sensitivity and specificity came to be higher, this test should be interpreted cautiously depending upon the prevalence of Corona Virus Disease 19 in that particular community and the clinical and epidemiological context of the person who has been tested. When in doubt by clinical correlation should be confirmed with Reverse Transcription Polymerase Chain Reaction.

Spleen in the thorax: A case report on traumatic diaphragmatic rupture

•

Diaphragmatic rupture is a rare complication of abdominal trauma.

•

Herniation of abdominal contents can occur following diaphragmatic rupture.

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Spleen was present in the thorax in a case following blunt abdominal trauma.

•

Care should be taken when inserting a chest tube in suspected cases.

•

Treatment is surgical via Laparotomy or Thoracotomy.

Introduction

Most of the cases of diaphragmatic rupture occur following abdominal trauma and herniation of abdominal organs into the thorax can occur.

Presentation of case

Twenty three years old male presented after a blunt abdominal trauma following a road traffic accident. Investigations revealed a left sided diaphragmatic rupture with herniation of spleen and stomach into the left hemithorax. Surgical repair of the defect was done and splenectomy had to be done due to extensive splenic laceration. Two third of the spleen was found in the left hemithorax.

Discussion

Diagnosis of diaphragmatic rupture can be missed in cases of polytrauma. High clinical suspicion with aids from imaging modalities help in the diagnosis. In suspicion of herniation of abdominal contents into the thorax, one should be careful in insertion of chest tube in view of damaging the herniated organs. Treatment is surgical repair and reduction of herniated contents.

Conclusion

Although a rare entity, diaphragmatic rupture can occur in cases of abdominal trauma. High clinical suspicion with imaging helps in the diagnosis.

Knowledge and Attitude Regarding Pubertal Changes among Secondary Level Students of Selected Schools of Dhulikhel Municipality

Background Adolescence is a transition phase of life during which a lot of pubertal changes occur. If not dealt properly, many mental and behavioral disturbances can result. Adolescents must have good knowledge and attitude regarding physical and psychosocial pubertal changes. Objective To assess the knowledge and attitude regarding pubertal changes among secondary level students of selected school of Dhulikhel Municipality. Method A quantitative, descriptive cross-sectional study was conducted among secondary level students of Dhulikhel Municipality. Study was conducted among students of grade 9 and 10 of four government and three private schools of municipality. After selection of seven schools, proportionate stratified random sampling technique was done followed by lottery method to select required number of students. Both descriptive statistics and inferential statistics were applied using Statistical Package for Social Science (SPSS) Version 25.0 for data analysis. Result The mean score of knowledge regarding pubertal changes was 26.2±2.9. Likewise, the mean attitude score regarding pubertal changes was 55.4±1.2. Knowledge regarding pubertal change was significantly higher among age group 15-17 years. Females had higher knowledge compared to males. Attitude related to pubertal change was significantly more in respondents who studied in government school. Conclusion Adolescents of Dhulikhel municipality schools had good knowledge and attitude about pubertal changes.

Anxiety and Depression during COVID-19 Pandemic among Medical Students in Nepal

Background Medical students' psychological response to societal lockdown during the COVID-19 pandemic has not been studied much. Objective To assess levels of anxiety and depression among medical students during initial stages of COVID-19 pandemic in Nepal and relate their distress to relevant variables. Method A cross-sectional study with online questionnaire was conducted among medical students at different colleges in Nepal. Hospital Anxiety and Depression Scale (HADS) detected 'anxiety' and 'depression'. The covariates were explored by logistic regression analyses. Result A total 416 medical students [mean age: 22.2 (2.1); males 57.7%, females 42.3%] participated. HADS-anxiety scores [mean: 7.1(4.3)] were significantly and positively correlated with HADS-depression [mean: 5.9 (4.1)] (r=0.695; p < 0.001). Point prevalence of total HADS caseness (HADS-T) was 26.7%. Specific HADS-defined caseness were: anxiety (HADS-A) 11.8%, depression (HADS-D) 5.5%, and comorbid anxiety and depression (HADS-cAD) 9.4%. All four types of caseness were significantly more prevalent among students with a history of mental problems (AOR=4.7, 3.2, 2.6, and 3.2 respectively). HADS-T was higher among those with a concurrent physical illness (AOR=2.4). HADS-T, HADS-A and HADS-D scores were higher among the age group > 22 years (AOR= 2.2, 2.5 and 4.4 respectively). HADS-cAD was almost threetimes higher among those with a possible COVID-19 exposure (AOR=2.8). Conclusion A significant number of medical students in Nepal suffered from high levels of anxiety and depression during the COVID-19 shut-down. The students in the higher (> 22 years) age group, those with past mental disorders, possible COVID-19 exposure, and concurrent physical illness showed elevated levels of anxiety and/or depression.

S-glutathionylation, friend or foe in cardiovascular health and disease

Glutathione is a low molecular weight thiol that is present at high levels in the cell. The high levels of glutathione in the cell make it one of the most abundant antioxidants contributing to cellular redox homeostasis. As a general rule, throughout cardiovascular disease and progression there is an imbalance in redox homeostasis characterized by reactive oxygen species overproduction and glutathione underproduction. As research into these imbalances continues, glutathione concentrations are increasingly being observed to drive various physiological and pathological signaling responses. Interestingly in addition to acting directly as an antioxidant, glutathione is capable of post translational modifications (S-glutathionylation) of proteins through both chemical interactions and enzyme mediated events. This review will discuss both the chemical and enzyme-based S-glutathionylation of proteins involved in cardiovascular pathologies and angiogenesis.

Diagnostic utility of ultrasonography and computerized tomography in gall bladder perforation: A case report

Gall bladder (GB) perforation can be misdiagnosed as any other more common cause of acute abdomen. We present a case of a 72-year-female who had presented to the emergency department with an acute abdomen. The clinical presentation and the biochemical markers had pointed towards acute pancreatitis. However, the ultrasonographic examination of the abdomen and the pelvis suggested GB perforation which was confirmed by the multislice computerized tomography scan. Following this the patient underwent open cholecystectomy and was successfully managed. The invaluable contributions from the radiological modalities led to the successful management of the patient.

Management of Different Types of Pneumothorax at Dhulikhel Hospital, Kathmandu University Hospital

Background Pneumothorax is defined as the presence of air in the pleural cavity. Pneumothorax can be classified as Spontaneous and Traumatic according to the etiology. Spontaneous pneumothorax is further classified as Primary and Secondary. Objective This study was conducted to know the management of different types of pneumothorax at Dhulikhel Hospital, Kathmandu University Hospital. Method This was a hospital based retrospective study conducted at Dhulikhel Hospital, Kathmandu University Hospital. Patients admitted in Surgery Ward with diagnosis of Pneumothorax from January 2018 to December 2019 were included in this study. Result This study included 144 patients with pneumothorax age ranging from 14 years to 94 years. Most of the patients were male with male:female ratio of 3.8:1. Eighty-four (58.03%) patients had Traumatic pneumothorax followed by Secondary spontaneous pneumothorax in 53(36.08%) patients and Primary spontaneous pneumothorax in seven (4.86%) patients. Among 144 patients, chest tube drain was required in 135 patients and nine patients were managed conservatively. One patient underwent Video Assisted Thoracoscopic Surgery (VATS) with Bullectomy and mechanical pleurodesis. Sixteen patients had persistent pneumothorax, among which six patients required chemical pleurodesis, two patients required negative suction therapy and five patients required both chemical pleurodesis and negative suction therapy. Conclusion This study showed pneumothorax to be more common in male population. Traumatic pneumothorax was the most common type followed by Secondary spontaneous pneumothorax and Primary spontaneous pneumothorax.

The Study of Burden of Family Caregivers of Patients Living with Psychiatric Disorders in Remote Area of Nepal

Background Family caregivers of psychiatric disorders likely to face burden. There is a paucity of data regarding the caregiver burden in psychiatric disorders in context of Nepal. Objective To study the caregiver burden in families with psychiatric illness and to find association between socio-demographic variables and caregiver burden in families with psychiatric illness. Method This is an analytical cross-sectional study. The participants (n=96) were caregiver of patients visiting outpatient department of two government of Nepal primary health care centers namely, Panchkhal Primary Health Care Center (PHC) Kavre District and Barhabise Health Care Center Sindhupalchowk district. The sample size has been determined by using statistical formula. Family burden assessment schedule (FBIS) was used for the study. Result The majority of the caregivers were females 56.3%. Most of the caregivers were aged below 45 years 54.2%. The large number of participants were single or separated 74%. The mean score of family burden assessment schedule was 27 ± 9.8 (range 0 to 48) with positive rate of 59.4%.Among the objective burden domains disruption of family leisure 61.5% was the most frequently reported burden. The subjective burden was reported in 95%. There were significant differential demographic associations with different domains of caregivers' burden. Conclusion Caregivers of Psychiatric patients experience different kind of burden of care. Our findings highlight the support to the family members to reduce their burden.

Open Surgical Management of Abdominal Aortic Aneurysm at a Community Based University Hospital in Nepal

Aortic aneurysms are abnormal dilatation of aorta. The risk factors include male sex, age > 65, smoking, coronary artery disease and hypertension. Here we report a case of infra-renal abdominal aortic aneurysm (AAA) of diameter 6 cm. The patient sucessfully underwent aorto-biiliac bypass surgery using Dacron Y graft. During abdominal aortic aneurysm surgery anesthetic challenge is also of paramount importance and should be considered.

Influence of Body Mass Index (BMI), Age and Gender on Stages of Varicose Vein in Newly Diagnosed Cases Following Screening Doppler in Outpatient Clinic

Background Varicose vein is one of the most common venous diseases which affect superficial veins especially of lower limb. This disease is characterized by prominent dilated veins, feeling of heaviness, itchiness, pigmentation, ulceration depending upon the stage of the disease. Objective This study was conducted to know how Body Mass Index, Age and Gender influence staging of varicose veins in our context. Method This is a cross sectional hospital based study conducted at Dhulikhel Hospital, Kathmandu University Hospital from April 2018 to March 2019. Patients with signs and symptoms of varicose vein were included in the study. Informed consent was taken from each patient and data collection done by filling the proforma. Result This study comprised 135 lower limbs with varicose vein from 108 patients. Male:Female ratio was 1.4:1. Mean age of patients was 44.47±12.65 (17-81) years. Significant correlation was found between increasing age and progression in Clinical staging of Varicose vein according to Clinical classification (p<0.05). Mean Great Saphenous Vein diameter at knee was found significantly higher in patients with more than five years of symptoms Mean Body Mass Index was not very different in different Clinical stage of Varicose veins. Conclusion This study showed that the Clinical Staging of Clinical Etiological Anatomical and Pathophysiological classification of varicose vein is significantly related to age. The mean diameter of Great Saphenous Vein at the level of Knee is significantly related to the duration of symptoms. However, the influence of Body Mass Index and gender on stages of varicose vein could not be established.

P1758The novel small leucin-rich repeat protein podocan is an independent predictor of major adverse cardiac events in patients with angiographically-defined coronary artery disease

Background

Smooth muscle cell (SMC) function determines the clinical course of vascular disease via fibrous cap stability. Podocan is an inhibitor of SMC function and is circulating in peripheral blood rendering it a candidate biomarker to predict MACE in patients with Coronary Artery Disease (CAD).

Purpose

We designed a prospective cohort study assessing the predictive value of Podocan for cardiovascular outcome (MI, CVA or death) in patients with CAD.

Methods

308 patients with angiographic evidence of CAD were enrolled. At index cardiac catheterization Syntax Score was calculated. For patient baseline characteristics see Table. Podocan and CRP-1 were measured using a human Podocan and CRP-1 ELISA. The Kaplan-Meier method was used to construct survival curves, which were compared using the log-rank test. Cox proportional hazard modeling was used for all univariate/multivariate analyses. Statistical analysis was performed using STATA.

Results

Podocan was detected in 212 patients (69%) with a detection threshold of 0.01 ng/ml. The median Podocan level observed was 1.4±8.2 ng/ml. 96 patients did not have a detectable Podocan level. Mean CRP-1 was 0.117±0.15 mg/ml. Mean Syntax Score was 12±9. Podocan did not correlate with CRP-1. There was also no association between Podocan and Syntax Score, age, BMI, smoking, LDL, and HDL, HgbA1c, LVEF and GFR. At the univariate level, presence of Podocan was associated with an increased rate of MACE (17% Podocan present vs. 7% Podocan absent, p=0.02). Kaplan-Meier survival analysis showed higher event free survival in patients with no detectable Podocan vs. detectable Podocan level (Figure). In a limited multivariate Cox proportional Hazard analysis, Podocan remained an independent predictor of MACE (HR: 2.5; P=0.042) in addition to diabetes, and LV ejection fraction.

Baseline Characteristics Total (N=308) Chronic ischemic heart disease (N=273) Acute coronary syndrome (N=35) Age (Year) 66.5±9.5 67±9 61±11 Female (Sex) 106 (33%) 90 (31%) 16 (46%) Hypertension 282 (89%) 244 (89%) 26 (74%) Diabetes 142 (44%) 124 (45%) 11 (31%) Hyperlipidemia 269 (87%) 243 (89%) 26 (74%) CRP (mg/dL) 0.11±0.14 0.10±0.13 0.18±0.19 LVEF (%) 49±10 49±10 48±9.5 CRP, C-reactive protein; LVEF, Left ventricular ejection fraction.

Kaplan Meier Survival Curves by Podocan

Conclusion

Podocan is a novel biomarker independently predicting MACE in secondary prevention of CAD warranting to be further studied in a Multicenter Clinical Trial.

Depression, Alcohol Use, Antiretroviral Therapy Adherence and HIV Status among HIV-infected from Multiple Antiretroviral Therapy Clinics in Nepal

Background Depression and alcohol use disorder are very common among people living with HIV infection, these disorders are not only common among HIV patients but also associated with antiretroviral therapy (ART) non adherence, morbidity and mortality. Objective The objective of our study is to study the prevalence of Depression, Alcohol use, and ART treatment adherence. Method This is a analytical cross-sectional study. Total of 221 participants were included in the study. Convenient method of sampling was used to collect the data from three district Kathmandu, Lalitpur and Kavre ART (Antiretroviral treatment) clinics. Beck Depression Inventory (BDI) was used for the assessment of depression, Alcohol use disorders identification test (AUDIT) was used for alcohol related problems and Visual analogue scale (VAS) was used for treatment adherence. Chi square test and multiple linear regression analysis were conducted for testing bivariate and multivariate relationship of sociodemographic and clinical factors with depression and treatment adherence. Result The 40% participants found to have depression. Variables associated with depression significantly after multiple regression analysis were employment (p value=0.04) and mode of transmission (p value= 0.003). More than half, 56% of the participant's CD4+ cells count was < 500 per cubic millimetre and 71% participant's viral load was undetectable. Clinical variables mode of transmission (pvalue=0.000), duration of illness (p value=0.03) and duration of treatment (p value=0.01) were significantly associated with depression. ART treatment adherence was significantly associated with CD4 cell (p value=0.02) and viral load (p value= 0.05). Conclusion Depression is very prominent among HIV positive patients. Low CD4+ cell count and high viral load has been seen among patients who are not adherent to antiretroviral treatment. It is suggested that clinicians should carefully assess the possibility of depressive symptoms in their patients on ART treatment.

Factors Affecting Recanalisation after Optimal Management of Deep Vein Thrombosis; A single institution based study

Background Presence of recanalisation will favour for better physiological recovery after medical management of Deep Vein Thrombosis (DVT) along with lesser chances of post thrombotic syndrome. Rate of recanalisation is varied and can range from 43-57% and the factors that affect recanalisation are still a dilemma. Objective To know the factors for recanalisation following Deep Vein Thrombosis. Method This is a single institution based retrospective-prospective analytical study encompassing all ultrasonologically diagnosed cases of Deep Vein Thrombosis in adults from January 2015 to November 2017. All the cases were admitted with oral warfarin bridged by Heparin/ Enoxaparin and were discharged once International Normalization Ratio was in therapeutic range. The patients were followed up for three months with minimal of three outpatient followup. Best finding in the doppler ultrasonography (done by Acuson P500, Seimens) in relation to recanalisation was taken for the study. Result There were 67 cases of Deep Vein Thrombosis. Of these cases male to female ratio was 0.91. The mean age was 48.07. Most common extent was up to common femoral vein (47.8%) followed by upto popliteal vein (40.3%). Remaining 11.9% had extension upto iliac veins. There was no recanalisation in 2 cases (3%). Partial recanalisation was seen in 23 cases (34.3%) while complete recanalisation was seen in 42 cases (62.7%). Recanalisation is more in DVT involving popliteal vein while it decreases as the extension goes up. In contrast to 79.4% complete recanalisation in popliteal vein, that in common femoral vein is 62.5% while in iliac vein is only 37.5%. Mean age in no recanalisation group is much younger than partial or complete recanalisation groups. Conclusion Recanalisation following Deep Vein Thrombosis distal to popliteal vein is more than that in proximal Deep Vein Thrombosis. The information on recanalization can be considered to use to decide upon the duration of medical management of Deep Vein Thrombosis.

Hydrogen sulfide: Therapeutic or injurious in ischemic stroke?

Hydrogen sulfide (H2S) has been identified as a vasodilatory, neuromodulatory, and anti-inflammatory gasotransmitter with antioxidant properties. Studies focused in cardiac tissue suggest H2S functions as a protective agent; however in the central nervous system (CNS) the effects of H2S during states of stress or injury, such as stroke, remain controversial. Currently, the application of H2S donors and modulators in stroke depends on the type of H2S donor and the timing of the therapy.

Awake Fiberoptic Intubation in Cervical Spine Injury: A Comparison between Atomized Local Anesthesia versus Airway Nerve Blocks

Background In cooperative patients with cervical spine injury, awake fiberoptic intubation is an excellent option for elective and semi urgent situations. It allows documentation of neurologic examination before and after intubation and surgical positioning. We have compared anesthesia of airway by nerve block and the local anesthesia atomizer undergoing awake fiberoptic intubation in cervical spine injury patients, in terms of the intubation time and discomfort. Objective To compare the intubation time and discomfort in patient with cervical spine injury with anticipated difficult airway potential to aggravate pre-existing injury undergoing awake fiberoptic intubation, based on cough and gag scores, between anesthesia of airway by (transtracheal and bilateral superior laryngeal) nerve block with local anesthetic agent and the local anesthesia atomizer. Method After institutional ethical approval and having informed written consent, 30 patients scheduled for elective surgery who require awake fiberoptic intubation, were included in the study. Patients were allotted by computer-generated random series into two groups; Group N received nerve block (transtracheal and bilateral recurrent laryngeal nerve block) and Group A received atomized lignocaine. Result The time taken for awake fiberoptic intubation was significantly lower in nerve blocks group as compared with the atomizer group [Group N: 90.2±11.7secs and Group A: 210.4±10.6 secs (p=0.041)]. Atomizer group had an increased coughing and gagging episodes than nerve block group [Group N: one patient, Group A: 11 patients (p=0.006)]. Ease of intubation and patient comfort were significantly better in nerve block group. Demographic and hemodynamic parameters were comparable in the two groups. Conclusion The nerve blocks (bilateral superior laryngeal and transtracheal recurrent laryngeal) provides adequate airway anesthesia, lesser patient discomfort, and faster intubation to aid in awake fiberoptic intubation in patients with anticipated difficult airway as compared to topical anesthesia using atomizer.

Chest Trauma Requiring Admission: Differences in Earthquake Victims and other Modes of Injury

Background The April 25, 2015 Nepal earthquake (7.8 Richter scale) followed by May 12, 2015 major aftershock (7.3 Richter scale) killed more than 9,000 people and injured more than 23,000 people. Dhulikhel Hospital situated at Kavre district of Nepal encountered major bulk of Earthquake victims residing at Sindhuplanchowk, Kavre and Dolakha districts during subsequent earthquake events. Objective To distinguish any significant differences in hospital admitted Earthquake and nonEarthquake chest trauma cases. Method Retrospective study was done comparing earthquake with non-earthquake chest trauma cases admitted in Dhulikhel Hospital. Study included parameters like mode of injury, time taken to reach health center, symptoms at presentation, involvement of chest area, presence and site of rib fracture, presence of hemothorax or pneumothorax, spectrum of treatment required, hospital admission days. Result There were total 23 earthquake victims of which 14 (61%) were female and rest of 9(39%) were male whereas out of total 95 non earthquake cases 23(24%) were female and 72 (76%) were male (p< 0.01). Mean age in earthquake victims was 53.73 (SD 18.33, range 19-84) while non earthquake cases was 46.83(SD 16.53, range 11-90), (p >0.05). Major mode of injuries in earthquake victims was hit by objects (82.60%) followed by fall (17.4 %). Incidence of rib fractures was 69.56% in earthquake victims and 85.26 % in non earthquake cases with average of 2-3 ribs in both cases (p>0.05). There was higher rates of pneumothorax in earthquake victims (52.17%) compared to non earthquake cases (30.52%), (p<0.05). There wasn't evidently major differences in incidence of pulmonary contusion, hemothorax and surgical emphysema. The mean duration of hospital admission days in earthquake victims was 7.78 days while non earthquake cases was 5.04 days (p >0.05). The total number of patients requiring chest tube insertion in earthquake victims was 16(69.56%) while that was 29(30.52 %) in non earthquake patients (p <0.01). Conclusion There was preponderance of female gender in earthquake related cases compared to non earthquake cases. Incidence of rib fracture was higher in earthquake victims. In earthquake victims, higher proportion of patient required chest tube drainage compared to non earthquake cases.

Students' Perception Regarding the Integration of Basic Sciences Courses in Nursing Curriculum

Background Integration of basic sciences course in nursing provides theoretical and clinical foundation in preparing clinically competent nurses to tackle todays' sophisticated health care system. Although basic sciences have always been considered as the subject of difficulty, there is paucity of evidence that explored the difficulties associated with the basic sciences courses in nursing curriculum. Objective To explore the difficulties experienced by the students and solutions to the difficulties related to basic sciences course from nursing students' perspective. Method A descriptive cross sectional study was conducted enrolling 164 nursing students. A self-administered semi structured questionnaire was used to collect data. Data were entered and analyzed descriptively in SPSS version 16 and information obtained was analyzed using descriptive and inferential statistics. Result Of the total 164 students, 93.3% perceived basic science as a difficult subject. Vast course content (79.73%), insufficient time allocation (40.52%) and integration of six basic sciences subjects into one (29.41%) were the major difficulties. Solution emphasized by students were to: make course specific to nursing (67.36%), organize frequent tests (61.11%), focus more on clinical implications (46.60%), increase credit hours (37.50%), conduct exams of six basic sciences subjects separately and provide examination feedback (29.36%). Entrance marks score was found to influence difficulty in basic sciences (p=0.01). Conclusion Basic science is considered as the difficult subject by nursing students. Necessary actions may be taken by the curriculum reviewer, college administration and the educators so as to minimize this difficulty among students.

Evaluation of OMNIgene®•SPUTUM-stabilised sputum for long-term transport and Xpert® MTB/RIF testing in Nepal

SETTING

German Nepal TB Project, National Tuberculosis Reference Laboratory, Kathmandu, Nepal.

OBJECTIVE

To evaluate whether transporting samples in OMNIgene®•SPUTUM (OM-S) reagent from a peripheral collection site to a central laboratory in Nepal can improve tuberculosis (TB) detection and increase the sensitivity of Xpert® MTB/RIF testing.

DESIGN

One hundred sputum samples were split manually. Each portion was assigned to the OM-S group (OM-S added at collection, airline-couriered without cold chain, no other processing required) or the standard-of-care (SOC) group (samples airline-couriered on ice, sodium hydroxide + N-acetyl-L-cysteine processing required at the laboratory). Smear microscopy and Xpert testing were performed.

RESULTS

Transport time was 2-13 days. Overall smear results were comparable (respectively 58% and 56% smear-negative results in the OM-S and SOC groups). The rate of smear-positive, Mycobacterium tuberculosis-positive (MTB+) sample detection was identical for both treatment groups, at 95%. More smear-negative MTB+ samples were detected in the OM-S group (17% vs. 13%, P = 0.0655).

CONCLUSION

Sputum samples treated with OM-S can undergo multiday ambient-temperature transport and yield comparable smear and Xpert results to those of SOC samples. Further investigation with larger sample sizes is required to assess whether treating sputum samples with OM-S could increase the sensitivity of Xpert testing in smear-negative samples.